Annual Seasonal Influenza Vaccine Refusal Form For Healthcare Workers printable pdf download

Annual Seasonal Influenza Vaccine Refusal Form For Healthcare Workers

*** SAMPLE ***

Annual Seasonal Influenza Vaccine Refusal Form for Healthcare Workers

Applicant Name: ___________________________ Phone: ______________Date: ___________

In accordance with section 5.4 of the Rules and Regulations Pertaining to Immunization, Testing,

and Health Screening for Health Care Workers [R23-17-HCW], a health care worker may refuse

the annual seasonal influenza vaccination requirement provided that he or she provides annual

written notice of such refusal prior to December 15 of each year to the health care facility in or at

which he or she is employed or volunteering, or with which he or she has an employment

contract by signing the statement below:

“I refuse to obtain the annual seasonal influenza vaccination. I understand that, by refusing such

vaccination, it is my professional licensing obligation to wear a surgical face mask during each

direct patient contact in the performance of my professional duties at any health care facility

during any declared period in which flu is widespread. I understand that the consequence for

failing to do so shall result in a one hundred dollar ($100) fine for each violation. Failing to do

so may also result in a complaint of Unprofessional Conduct being presented to the licensing

board that has authority over my professional license. I understand that such licensing

complaint, if proven, may result in a sanction such as reprimand, or suspension or revocation of

my professional license.”

Signature of Applicant: _______________________________ Date: __________________

Annual Seasonal Influenza Vaccine Refusal Form For Healthcare Workers